Provider Demographics
NPI:1063618510
Name:MATTSON, DORIAN L (DC)
Entity type:Individual
Prefix:MRS
First Name:DORIAN
Middle Name:L
Last Name:MATTSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 E AYER ST
Mailing Address - Street 2:
Mailing Address - City:IRONWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49938-2204
Mailing Address - Country:US
Mailing Address - Phone:906-932-4605
Mailing Address - Fax:906-932-4875
Practice Address - Street 1:520 E AYER ST
Practice Address - Street 2:
Practice Address - City:IRONWOOD
Practice Address - State:MI
Practice Address - Zip Code:49938-2204
Practice Address - Country:US
Practice Address - Phone:906-932-4605
Practice Address - Fax:906-932-4875
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-22
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301007489111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38934400Medicaid
MA4361323OtherUPHP
BLUE CROSSOther950B710200
BLUE CROSSOther950B710200
ON82590001Medicare ID - Type Unspecified